Target fluid therapy

Surat Tongyoo
Critical Care Medicine
Siriraj Hospital, Mahidol University
 Diagnosis causes of shock
• Vasoconstrictive (low cardiac output) shock
• Hypovolemic shock
• Cardiogenic shock
• Obstructive shock
• Cardiac tamponade
• Massive pulmonary embolism
• Tension pneumothorax
• Distributive (high cardiac output) shock
• Septic shock
• Severe pancreatitis
• Adrenal insufficiency
Jean-Louis Vincent, N Engl J Med 2013
Shock management
• Hemodynamic management
• Preload
• Distributive shock (66%)
• Hypovolemic shock (16%)
• Obstructive shock (2%)
• Contractility
• Some distributive shock
• Cardiogenic shock
• Afterload
• Some distributive shock
• Cardiogenic shock
• Specific management

Jean-Louis Vincent, N Engl J Med 2013

Principle of fluid therapy
PCWP

SV LVEDV

A B LVEDV, PCWP
Principle of fluid therapy
PCWP

SV LVEDV

A B LVEDV, PCWP
 Inadequate
Fluid overload
fluid

Inadequate tissue perfusion Increase risk of infection
Microvascular dysfunction Prolong intubation
Acute kidney injury Interstitial edema
Bowel ischemia Pulmonary edema
Shock liver Hypoxemia
Death

Optimal fluid
Conceptual volume status during resuscitation 

Fluid bolus

Haste EA Br J Anaesth 2014;113(5):740‐7
 Shock
- BP < 90/60 mmHg
- SBP < 80% of baseline
- Evidence of inadequate tissue perfusion

No or low risk of Some risk of fluid Definite fluid

fluid overload overload overload
Age < 50 Elderly patient Elderly patient
CAD, DM, HT, PVD, CRI
No underlying disease CAD, DM, HT, PVD, CRI
Crepitation > 2/3
Evidence of fluid loss Crepitation < 2/3 Frank pulmonary edema
No crepitation No cardiogenic shock Cardiogenic shock

Fluid loading Fluid responsive No indication for

1 L in 1st hour
test fluid therapy
4-6 L in 3-6 hrs Consider other treatment
Fluid responsive test 
Definition:
• The accurate assessment of the likelihood that the patient will 
respond (increase stroke volume) to fluid resuscitation
Fluid responsive test 
• Static test • Dynamic test
• JVP, CVP • Fluid challenge test
• PCWP • Passive leg raising test
• LV volume • IVC diameter variation
• Pulse pressure variation
• Stroke volume variation
 Some risk of fluid
overload

Fluid responsive test

CVP or PCWP No CVP

monitoring monitoring

Fluid
challenge test
Initial CVP
• Low CVP < 6 cmH2O 
• Inadequate volume
• CVP = 15 cmH2O = 11 mmHg
• Volume overload?

• Spontaneous breathing • Mechanical ventilation
• No vasopressor • PCV
• IP = 15, PEEP = 5 cmH2O
• Lung crepitation
• Vasopressor
• Norepinephrine 0.2 mcg/kg/min
• No lung crepitation
Effect of intrathoracic pressure

10 mmHg 10 mmHg 10 mmHg

-5 mmHg 10 mmHg 0 mmHg

Spontaneous Mechanically End expiration

inspiration inspiration intrathoracic P = 0 mmHg
CVP = 5 mmHg CVP = 20 mmHg CVP = 10 mmHg
(10-5) (10+10) (10+0)
Intrathoracic pressure variation
Spontaneous respiration

Mechanical ventilation
 CVP guided fluid challenge test

Initial CVP Fluid infusion

Evaluate
cmH2O (mmHg) rate in 10-15 min

Fluid responsive
<10 (8) 200 mL
-CVP increase < 2 (2)
-MAP increase > 10%
10-15 (8-12) 100 mL
Not respond to fluid
-CVP increase > 5 (3-4)
>15 (>12) 50 mL
-MAP not increase
Limitation of fluid challenge test

• Invasive monitoring
• CVP, PCWP

Site Internal jugular Subclavian Femoral

Arterial puncture 6.3 - 9.4 3.1 - 4.9 9.0 - 15.0
Hematoma 0.1 - 2.2 1.2 - 2.1 3.8 - 4.4
Hemothorax NA 0.4 - 0.6 NA
Pneumothorax 0.1 - 0.2 1.5 - 3.1 NA

David C. McGee, N Engl J Med 2003

 Some risk of fluid
overload

Fluid responsive test

CVP or PCWP No CVP

monitoring monitoring

Fluid Mechanical Spontaneous

challenge test ventilator breathing

Pulse pressure variation Passive leg raising test

IVC diameter variation IVC diameter variation
Passive leg raising test
Heart‐Lung interaction
EP=5 cmH2O Expiration
-Lower intrathoracic pressure
-Increase venous return
-IVC collapse

IP=25cmH2O Inspiration
-Higher intrathoracic pressure
-Decrease venous return
-IVC expansion
 Heart-Lung interaction
EP=5 cmH2O
• Require curtained and fixed
different between respiratory phase
• IP-EP > 10 cmH2O
• Tidal volume > 8-10 ml/kg

• No patients respiratory effort

• Decrease pressure different
IP=25cmH2O
• Reverse intra-thoracic pressure if the
patient had ventilator dys-synchrony
IVC diameter variation
• Vertical subxiphoid view
 IVC diameter variation

IVC

• Variation of IVC diameter during respiratory phases associates with

intravascular volume status
• Enhance IVC diameter variation in volume depletion patient
• Blunt variation in relatively hypervolemic patients
IVC diameter variation
 Respiratory variation of IVC dimension
predict fluid responsiveness
 IVC distensibility index (dIVC)

IVCD max – IVCD min × 100

IVC D min

 dIVC > 18% predict a respond to fluid infusion

(7 ml/kg of plasma expander) with increasing of
cardiac index > 15%
Barbier C, et al. Intensive Care Med (2004) 30:1740-6
IVC diameter variation = Fluid responsive

• dIVC = 95%
• CI = 1.8 l/min/sq.m

• After 7 ml/kg iv fluid

• dIVC = 28%
• CI = 2.6 l/min/sq.m

Barbier C, et al. Intensive Care Med (2004) 30:1740-6

No IVC diameter variation = No fluid responsive

• dIVC = 0%
• CI = 2.3 l/min/sq.m

• After 7 ml/kg IV fluid

• dIVC = 0%
• CI = 2.3 l/min/sq.m

Barbier C, et al. Intensive Care Med (2004) 30:1740-6

IVC diameter variation in spontaneous 
breathing patients
• IVC collapsibility index
IVCDmax – IVCDmin x 100
IVC expiration

• Cut point > 40%

• Sensitive but less specific
for detect fluid
responsive patients

Muller L. Critical Care 2012

Heart‐Lung interaction during mechanical 
ventilation
RV: RV:
-Decrease RV preload -Increase RV preload
-Increase RV afterload -Decrease RV afterload
-Decrease RVSV -Increase RVSV
-IVC dilated -IVC collapse

Expiration:
-Decrease lung volume
-Decrease PVR
-Blood pulling in lung
Inspiration:
-Lung expand
-Increase PVR
-Squeeze blood into LV

LV: LV:
-Increase LV preload -Decrease LV preload
-Decrease LV afterload -Increase LV afterload
-Increase LVSV -Decrease LVSV
-Max pulse pressure at -Min pulse pressure at
end inspiration end inspiration
Heart-Lung interaction

Max pulse pressure at Min pulse pressure at

end inspiration end expiration
Pulse pressure variation

In Gunn Et Al 2001 Pulse Pressure Variation Picture

 Pulse pressure vs Stroke volume
• There is a good correlation between pulse pressure (PP)
and stroke volume (SV) in normal people
• SV can be estimated from PP by 2 ways
• Calibrated SV
• Need thermodilution technique
• Non-calibrated SV
• PiCCO
• Need patient’s baseline information
• Age, sex, height and body weight
• Vigilio-Flotac
 Pulse pressure variation (PPV)
• PPV = [(Max PP – Min PP) ÷ Mean PP] x 100
• During mechanical ventilation, PPV > 10-15% correlated
with increasing of cardiac index about 15% after fluid
resuscitation

• Stroke volume variation

• Systolic blood pressure variation
 Result

• Include 29 studies
• Enrolled 685 patients
• 56% of patients responded to fluid
resuscitation
• Objective:
• To evaluate the accuracy of SPV, PPV,
and SVV in predicting fluid
responsiveness
• To compare these variables to the static
hemodynamic variables, which have
been used to assess intravascular
volume
Crit Care Med 2009; 37:2642–2647
Limitation of PPV & IVC diameter
variation to evaluate fluid responsive
• Required mechanical ventilation
• High enough tidal volume/inspired pressure
• TV > 8-10 mL/kg
• No spontaneous respiration
• Lung compliance < 30 mL/cmH2O
• No cardiac arrhythmia
• No increase intra-abdominal pressure
Passive legs raising test
• Measure cardiac output in the semi-upright
position

45o
• Tilt the upper part of the patient down and
elevate patient’s legs

• Measure cardiac output during both legs

elevation
45o

• Increasing of CO > 10-15% indicate positive

fluid responsive test
Passive legs raising test
• Maximum increase CO after legs elevation
within 30-90 seconds

45o
• The increasing of CO may not persist after 60-
90 seconds

• Can be used in cardiac arrhythmia patients

45o
Passive legs raising test
Limitation of PLRT
• Require continuous CO monitoring
• Not suitable in high intra-abdominal pressure
• Not suitable in post thoracic, abdominal surgery
45o

patients

45o
Guideline for fluid resuscitation
• Initial fluid resuscitation
• 20‐30 mL/kg crystalloid solution
• 800‐1,000 mL in 1st hour
• Total 1,500‐2,500 mL in 3rd hours
• Consider colloid if unable to achieve hemodynamic goal and 
evidence of fluid responsive
• Albumin is the most preferable colloid
• Avoid hydroxyethyl starch in septic shock patients
• Maintenance fluid after achieve macro & microcirculation goal
• Increase rate as need
• Invasive vs non‐invasive test
 When to stop fluid therapy?
• Achieve hemodynamic goal
• Mean arterial pressure > 65 mmHg
• Urine output > 0.5mL/kg/hours
• Decrease serum lactate

• No fluid respond
• Rapid increasing of CVP
• Unable to increase BP, SV after fluid therapy

• Complication of fluid therapy
• Hypoxemia & increasing lung crepitation
 When to stop fluid therapy?
• Achieve hemodynamic goal
• Mean arterial pressure > 65 mmHg
• Urine output > 0.5mL/kg/hours
• Decrease serum lactate

• No fluid respond
• Rapid increasing of CVP
• Unable to increase BP, SV after fluid therapy

• Complication of fluid therapy
• Hypoxemia & increasing lung crepitation
Data from our patients
• 310 septic shock
Fluid 0‐3 hour (mL/kg)
• Mean BW = 58.5+13.5 kg
• Hospital mortality = 23.5%
• 23%, 19%, 34.9%
Fluid 1st hour (mL/kg)
THANK YOU
 Shock Diagnosis & Specific treatment

Early Cardiogenic shock

management Hx: Risk of CAD, chest pain
PE: Vasoconstrictive + Pulmonary edema
ECG: ST elevation, LBBB, Q wave
Px: Early revascularization
Optimized
Hypovolemic shock
preload
Hx: Blood or volume loss
PE: Vasoconstrictive + Lung clear
Px: Stop ongoing loss
Restore Septic shock
blood pressure Hx: Fever + SIRS + source of infection
PE: Vasodilatory shock
Px: Appropriate antibiotic and drainage
Adequate Obstructive shock
tissue perfusion Hx: Risk of DVT/PE, malignancy, CRF
PE: Vasoconstrictive + Lung clear
Px: Fluid, vasopressor, specific treatment
SAFE study Critically ill patients, N = 6,997  4% albumin vs NSS 28 d mortality
NEJM 2004 ‐Mean BP 74 mmHg 34% vs 35%, P = 0.96
43% surgical patients Sepsis    30.7% vs 35.3%, P = 0.09
19% severe sepsis Trauma 13.6% vs 10%, P = 0.06
17% trauma
Hydroxyethyl starch Critically ill patients, N = 7,000 6% HES vs NSS 90 d mortality  
NEJM 2012 ‐Mean BP = 74 mmHg 18% vs 17%, P = 0.26
45% required vasopressor CHF        36.5% vs 39.9%, P = 0.03
29% severe sepsis RRT           7% vs 5.8%, P = 0.04
8% trauma Sepsis    25.4% vs 23.7%, P = 0.38
Hydroxyethyl starch Severe sepsis, N = 798 6% HES vs RLS 90 d mortality
NEJM 2012 55% lung infection 51% vs 43%, P = 0.03
33% abdominal infection Bleed  10% vs 6%, P = 0.09
RRT      22% vs 16%, P = 0.04
CRISTAL trial Shock patients, N = 2,857 Colloid vs Crystalloid 28 d mortality 
JAMA 2013 ‐SBP = 92 mmHg 645 HES 25.4% vs 27%, P = 0.26
54% septic shock 281 Gelatin 90 d mortality
40% hypovolemic shock 80 Albumin 30.7% vs 34.2%, P = 0.03
6% trauma
ALBIOS study Severe sepsis, N = 1,818 20% Albumin vs Crystalloid 28 d mortality 31.8% vs 33.2%, P = 0.97
NEJM 2014 ‐Mean BP = 74 mmHg 90 d mortality 41.1% vs 43.6%, P = 0.29
62% septic shock Septic shock 43.6% vs 49.9%, P = 0.03
 Compensatory shock vs Decompensatory shock
Stage Estimated  Heart rate Blood pressure Urine output
blood loss
Early blood loss < 500 mL Normal Normal Decrease
Slightly increase
Compensatory  500‐1,000 mL Increase > 10‐15% Postural  Decrease
shock hypotension
Decompensatory 1,000‐1,500 mL Significant increase  SBP < 90 mmHg < 0.5 
shock > 15‐20% MBP < 70 mmHg mL/kg/hr
Irreversible shock > 1,500 mL  Significant increase  Profound shock Absent
without  > 20%
resuscitation
Common problems in shock management
• Shock recognition
• Diagnosis cause(s) of shock
• Shock management
• Fluid resuscitation: Type of fluid & Rate of administration
• Vasopressor: Which one is better?
• Specific treatment cause(s) of shock
• End point of shock resuscitation
• Macrocirculation: Blood pressure level
• Microcirculation: Tissue perfusion
• Continuing care
Which patient is in shock?
• Blood pressure drop
• SBP < 90 mmHg
• SBP decreasing > 40 mmHg from baseline
• Mean ABP < 70 mmHg
• Mean ABP decreasing > 20% of baseline
• Other V/S change
• Increase HR, RR
• Evidence of inadequate tissue perfusion
• Clinical: peripheral vasoconstriction, delay capillary refill, alteration of 
consciousness, decrease urine output
• Laboratory: Lactate > 4 mmol/L, deterioration of kidney function